Elizabeth Santa Ana, Ph.D.; Brian Lozano, Ph.D.Elizabeth Santa Ana, Ph.D.; Brian Lozano, Ph.D.

Ralph H. Johnson VA Medical CenterRalph H. Johnson VA Medical Center

Homeless Outreach MeetingHomeless Outreach MeetingColumbia, SCColumbia, SC

July 23rd, 2014July 23rd, 2014

Adapting Motivational InterviewingAdapting Motivational Interviewing for Homeless Outreach Servicesfor Homeless Outreach Services

OutlineOutline1. What is Motivational Interviewing (MI)?1. What is Motivational Interviewing (MI)?

2. In what ways is MI useful for engaging 2. In what ways is MI useful for engaging homeless individuals in services?homeless individuals in services?

3. How can MI be used flexibly?3. How can MI be used flexibly?

4. How can MI be adapted to the setting 4. How can MI be adapted to the setting where you are meeting a homeless where you are meeting a homeless individual?individual?

5. What concerns do you have using MI 5. What concerns do you have using MI with homeless individuals?with homeless individuals?

What is MI?What is MI?

What have you already learned What have you already learned or heard about Motivational or heard about Motivational

Interviewing?Interviewing?

Motivational Interviewing is:Motivational Interviewing is:……a conversation about behavior change a conversation about behavior change

……explores ambivalenceexplores ambivalence……uses reflective (person-centered) listening uses reflective (person-centered) listening (among other skills)(among other skills)

……emphasizes the person’s emphasizes the person’s ownown reasons for change reasons for change

……collaborative & imparts acceptance and compassioncollaborative & imparts acceptance and compassion

It is a strategic conversational method to help a person It is a strategic conversational method to help a person move toward a particular change goal:move toward a particular change goal:

……that uses specific counseling skills to elicit, strengthen that uses specific counseling skills to elicit, strengthen and reinforce client and reinforce client change talkchange talk

……and provides a way to respond to discord (non-change and provides a way to respond to discord (non-change talk) in a non-confrontational waytalk) in a non-confrontational way

Motivational InterviewingMotivational Interviewing

Is an Evidence-Based Practice associated Is an Evidence-Based Practice associated with improved health outcomes.with improved health outcomes.

Can be used in brief encounters.Can be used in brief encounters.

NOTENOTE: Not a panacea…: Not a panacea…appropriate for appropriate for people who are ambivalent,people who are ambivalent, but may not but may not be useful for people completely ready to be useful for people completely ready to change or people determined to make change or people determined to make no changes.no changes.

You approach an individual living on the You approach an individual living on the street and inform him about homeless street and inform him about homeless services.services.

The person thanks you and doesn’t The person thanks you and doesn’t seem interested.seem interested.

You tell the person that you really think You tell the person that you really think he can benefit from the services.he can benefit from the services.

The person gives you a reason why he The person gives you a reason why he can’t participate in the services can’t participate in the services (his dog, his (his dog, his friends, etc.). friends, etc.).

What do you do?What do you do?

The Nature of the Problem: One ScenarioThe Nature of the Problem: One Scenario

The nature of the problem The nature of the problem (continued)…(continued)…

You again recommend the person use the You again recommend the person use the homeless services.homeless services.

You provide logical reasons why he should You provide logical reasons why he should do so.do so.

Perhaps you remind the person of the Perhaps you remind the person of the health consequences if he doesn’t get off health consequences if he doesn’t get off the street.the street.

Does the person argue or does he agree?Does the person argue or does he agree? The person say he’s fine…The person say he’s fine…

……and still no change is madeand still no change is made

What’s going on?What’s going on? Why isn’t this person jumping on the Why isn’t this person jumping on the

offer to get off the street?offer to get off the street?

The person may want to get off the The person may want to get off the street, but may be conflicted.street, but may be conflicted.

““AmbivalenceAmbivalence is a state of having is a state of having simultaneous, conflicting simultaneous, conflicting feelings toward something” – Thanks Wikipedia!toward something” – Thanks Wikipedia!

Or, feeling the same way about two Or, feeling the same way about two different conflicting thingsdifferent conflicting things

We can’t assume that We can’t assume that because we have a service because we have a service we know is helpful that we know is helpful that people are going to people are going to understand it, be motivated understand it, be motivated to use it initially, or decide to use it initially, or decide immediately how the service immediately how the service will fit into their lives. will fit into their lives.

How NOT to address How NOT to address ambivalenceambivalence

Our first instinct is often to provide information Our first instinct is often to provide information to “make it right,” to persuade or convince the to “make it right,” to persuade or convince the person to do something using logic.person to do something using logic.

Why may it be ineffective?Why may it be ineffective?

Hypothesis:Hypothesis: If someone is AMBIVALENT and we If someone is AMBIVALENT and we argue for one side of an issue, their reflex will argue for one side of an issue, their reflex will be to defend the OPPOSITE side of the issue. be to defend the OPPOSITE side of the issue.

It is human nature to assert our autonomy It is human nature to assert our autonomy if/when we feel our freedom is being if/when we feel our freedom is being threatened threatened (“Psychological Reactance”)(“Psychological Reactance”)

We share the responsibility for enhancing our client’s motivation for change.

Clients are not responsible for being sufficiently motivated for change at the outset.

Motivation is malleable and is formed in the context of relationships.

Motivation is not a trait:Motivation is not a trait:

Review of MI: Spirit and Basic SkillsReview of MI: Spirit and Basic Skills While we talk to patients, we want to emphasize While we talk to patients, we want to emphasize

their their AUTONOMYAUTONOMY, talk in a , talk in a COLLOBORATIVECOLLOBORATIVE (partnership) manner and (partnership) manner and EVOKEEVOKE their values and their values and abilities. abilities.

In this context we use the following skills…In this context we use the following skills… Open-ended questionsOpen-ended questions Affirmations (reflecting a patient’s sense of Affirmations (reflecting a patient’s sense of

his/her own accomplishment)his/her own accomplishment) Reflections (MOST IMPORTANT SKILL!)Reflections (MOST IMPORTANT SKILL!) SummariesSummaries

OARS: Basic MI Skills…OARS: Basic MI Skills… Open-ended questionsOpen-ended questions: Can’t be answered with a simple : Can’t be answered with a simple

YES or NO. YES or NO. ExamplesExamples: “What brings you here today? : “What brings you here today? Tell about…Tell me more about that… How might I be of Tell about…Tell me more about that… How might I be of help to you?....”help to you?....”

AffirmationsAffirmations:: NOT praise, but a reflection of the patient’s NOT praise, but a reflection of the patient’s sense of accomplishment. sense of accomplishment. ExEx.: “You’re managed to stay .: “You’re managed to stay sober since living on the street.”sober since living on the street.”

ReflectionsReflections:: Paraphrasing, mirroring what patient says, Paraphrasing, mirroring what patient says, labeling emotions. labeling emotions. ExEx.: “You are worried about your .: “You are worried about your health if you continue to live on the street …You seem health if you continue to live on the street …You seem worried about your diabetes…”worried about your diabetes…”

SummarizingSummarizing:: Brings all the above together in a Brings all the above together in a summarizing statement summarizing statement highlighting client change talk.highlighting client change talk.

Goal of MIGoal of MI Providers often hope that Motivational Providers often hope that Motivational

Interviewing will motivate individuals to Interviewing will motivate individuals to immediately engage in desired behaviors.immediately engage in desired behaviors.

But MI Involves But MI Involves engaging in a conversation engaging in a conversation in in the spirit of Partnership, Acceptance, the spirit of Partnership, Acceptance, Collaboration, and Evocation, using OARS…Collaboration, and Evocation, using OARS…

…….To elicit and strengthen .To elicit and strengthen Change TalkChange Talk……

The theory of MI: Increased Client Change Talk -The theory of MI: Increased Client Change Talk -> eventual change> eventual change

Can happen quickly…. or over time as a process Can happen quickly…. or over time as a process (may take several MI conversations)(may take several MI conversations)

What is Client Change Talk?What is Client Change Talk? Client language that moves toward changeClient language that moves toward change

Opposite from “Sustain Talk” – these are the Opposite from “Sustain Talk” – these are the reasons that clients give to defend their behavior.reasons that clients give to defend their behavior.

Specific to a particular target behavior or set of Specific to a particular target behavior or set of target behaviors. target behaviors.

Usually initiated by the client, but also elicited by Usually initiated by the client, but also elicited by the mental health professional.the mental health professional.

Expresses patient’s desires, ability, reasons, & need Expresses patient’s desires, ability, reasons, & need to change. to change.

States willingness & intention to change.States willingness & intention to change.

Support for MI in the Homeless Support for MI in the Homeless PopulationPopulation

Adopting best practices Project: Adopting best practices Project:

Lessons learned in the Collaborative Lessons learned in the Collaborative Initiative to Help End Chronic Initiative to Help End Chronic

Homelessness (CICH) Homelessness (CICH) (McGraw et al., 2010)(McGraw et al., 2010)

Collaboration of 5 AgenciesCollaboration of 5 Agencies: : -Substance Abuse and Mental Health Services Administration (SAMHSA)-Substance Abuse and Mental Health Services Administration (SAMHSA)

-Housing and Urban Development-Housing and Urban Development

-Department of Veterans Affairs-Department of Veterans Affairs

-Health Services and Resources Administration-Health Services and Resources Administration

-U.S. Interagency Council on Homelessness-U.S. Interagency Council on Homelessness

11 programs, nation-wide, chosen to apply models of 11 programs, nation-wide, chosen to apply models of best practices to support clients in housingbest practices to support clients in housing

Collaborative Initiative to Help End Collaborative Initiative to Help End Chronic Homelessness (CICH)Chronic Homelessness (CICH)

Primary Goal of CICH:Primary Goal of CICH: Provide supportive services Provide supportive services using clinical practices shown to be effective or “based using clinical practices shown to be effective or “based on sound evidence” in the engagement and retention on sound evidence” in the engagement and retention of clients in housing services. of clients in housing services.

Survey on the application of two models: Survey on the application of two models: • Assertive Community Treatment (ACT) Assertive Community Treatment (ACT) • Motivational Interviewing (MI)Motivational Interviewing (MI)

McGraw and colleagues report on the experiences of the CICH McGraw and colleagues report on the experiences of the CICH projects in their use of ACT and MI.projects in their use of ACT and MI.

Perceived Benefits of MI: CICH FindingsPerceived Benefits of MI: CICH Findings

Survey of team members reported positive changes Survey of team members reported positive changes such that their clients: such that their clients:

took dramatic steps to engage in treatment and took dramatic steps to engage in treatment and reduce substance use.reduce substance use.became more open to discuss persistent medical became more open to discuss persistent medical problems with staff.problems with staff.seemed to develop trust, leading them to talk about seemed to develop trust, leading them to talk about their concerns and hopes.their concerns and hopes.

Staff associated changes with providing unconditional Staff associated changes with providing unconditional acceptanceacceptance: : Conveying “the belief in him” and his ability to change. Conveying “the belief in him” and his ability to change. ““Sticking with him” through good days and bad days. Sticking with him” through good days and bad days.

Why use MI with the Homeless Why use MI with the Homeless Population?Population?

1.1.Practice that is most compatible with the Housing First Practice that is most compatible with the Housing First philosophyphilosophy

2.2.Client-centeredClient-centered

3.3.Imparts respect for client choice and self-directionImparts respect for client choice and self-direction

4.4.Enhances a culture of trust and hopeEnhances a culture of trust and hope

5.5.Fosters positive client change and recoveryFosters positive client change and recovery

6.6.More likely to enhance intrinsic-motivation for changeMore likely to enhance intrinsic-motivation for change

Using MI has been shown toUsing MI has been shown to (McGovern et al., 2010): (McGovern et al., 2010):

1.1.Increase rate at which clients begin treatmentIncrease rate at which clients begin treatment

2.2.Enhance length of time clients remain in treatmentEnhance length of time clients remain in treatment

3.3.Motivate adherence to treatment recommendationsMotivate adherence to treatment recommendations

4.4.Reduce substance useReduce substance use

5.5.Motivate adherence for taking prescribed medicationsMotivate adherence for taking prescribed medications

Using MI Flexibly: Some SuggestionsUsing MI Flexibly: Some Suggestions

1. During the information gathering process, 1. During the information gathering process, MI may be ‘woven in’ MI may be ‘woven in’ (think of a container of (think of a container of glass beads….the water poured in is MI).glass beads….the water poured in is MI).

2. Engage the client first (get to know his 2. Engage the client first (get to know his values, what is important to him).values, what is important to him).

3. Use a couple of open-ended questions, 3. Use a couple of open-ended questions, followed by a few reflections.followed by a few reflections.

4. It’s okay to use MI for just a few minutes.4. It’s okay to use MI for just a few minutes.

Using MI Flexibly: Some SuggestionsUsing MI Flexibly: Some Suggestions

5. It may take a few conversations for any change 5. It may take a few conversations for any change to occur. to occur.

6. Decide to ‘plant a seed’ (may not have an 6. Decide to ‘plant a seed’ (may not have an outcome right away). MI has been shown to work outcome right away). MI has been shown to work over time. over time.

7. 7. Ask:Ask: “How willing are you to talk about this?” “How willing are you to talk about this?”

AskAsk: “Tell me what it is like for you to live here” : “Tell me what it is like for you to live here”

OROR—”What are some of the challenges that —”What are some of the challenges that you face?” you face?” (get an understanding of the person’s (get an understanding of the person’s circumstances)circumstances)

In terms of using MIIn terms of using MI

What Challenges Do You What Challenges Do You Have Engaging People In Have Engaging People In

Homeless Services?Homeless Services?

““Unless I am Formally Trained in MI, I Can’t Unless I am Formally Trained in MI, I Can’t Use It”Use It”

Almost all of us have the ability to:Almost all of us have the ability to: Make an open-ended questionMake an open-ended question Repeat something a person just said Repeat something a person just said

using slightly different wordingusing slightly different wording Emphasize someone’s strengthsEmphasize someone’s strengths Repeat something a person just said that Repeat something a person just said that

involves changeinvolves change

(The use of at least one of these skills is better than (The use of at least one of these skills is better than none) none)

““I’m not sure where and when can I use MI”I’m not sure where and when can I use MI”

1.1.During outreach contacts:During outreach contacts:• In the street (noisy, crowded, chaotic)In the street (noisy, crowded, chaotic)• Soup kitchen (noisy, crowded, chaotic)Soup kitchen (noisy, crowded, chaotic)

2.2.As the client enters the front door As the client enters the front door (front desk staff)(front desk staff)

3.3.Initial interviews to determine interest and Initial interviews to determine interest and eligibilityeligibility

4.4.Once client is in services: On-going week-to-Once client is in services: On-going week-to-week discussions about employment, daily week discussions about employment, daily activities, self-care, etc.activities, self-care, etc.

5.5.Medical and behavioral needsMedical and behavioral needs

6.6.Treatment planningTreatment planning

Essentially: During any interactions with Essentially: During any interactions with clients!clients!

TIMETIME

““MI takes time to doMI takes time to do”:”: It takes time to learn, but can be done in It takes time to learn, but can be done in

brief fashion when mastered.brief fashion when mastered.

Sometimes just a minute or two Sometimes just a minute or two (combined) of reflective listening can (combined) of reflective listening can diffuse tension and make people more diffuse tension and make people more receptive.receptive.

Can save time for the future.Can save time for the future.

““If all you have is a few minutes, you If all you have is a few minutes, you can’t afford not to do MI.” can’t afford not to do MI.” (Bill Miller, personal (Bill Miller, personal communication)communication)

““I’m not sure how to begin a conversation using MI”I’m not sure how to begin a conversation using MI”

A. Elicit-Provide-Elicit (E-P-E)A. Elicit-Provide-Elicit (E-P-E)

E:E: “Would it be okay with you if I talked with “Would it be okay with you if I talked with you a little bit about our housing services?”you a little bit about our housing services?”

KeyKey: “What if anything, do you know about : “What if anything, do you know about them already?”them already?”

P:P: “Yes…that’s true….and we also “Yes…that’s true….and we also provide…..”provide…..”

E:E: “How might any of these services, if any “How might any of these services, if any of them, fit into your life?”of them, fit into your life?”

““What if the person refuses services after EPE?”What if the person refuses services after EPE?”

““What is life like for you on the street?” What is life like for you on the street?” (reflect—Note: this may involve (reflect—Note: this may involve reflecting personal values)reflecting personal values)

““What challenges, if any, do you What challenges, if any, do you experience living here?” (reflect)experience living here?” (reflect)

Summarize, pointing out any ‘change Summarize, pointing out any ‘change talk’ placed on the back end of the talk’ placed on the back end of the summary.summary.

End with permission to talk again.End with permission to talk again.

Example of a summaryExample of a summary

So Mr. Stephenson, let me summarize what I heard you say today. So Mr. Stephenson, let me summarize what I heard you say today. You’ve been living on the street for about 3 years now. You’ve You’ve been living on the street for about 3 years now. You’ve really managed to take care of yourself quite well on the street. really managed to take care of yourself quite well on the street. For the most part, you know where to find food and you are pretty For the most part, you know where to find food and you are pretty good at seeking shelter when the weather is bad. You have made good at seeking shelter when the weather is bad. You have made some good friends and it would be hard to leave them, and you some good friends and it would be hard to leave them, and you are really used to this neighborhood. are really used to this neighborhood. On the other hand, you are On the other hand, you are really worried about your diabetes and you are thinking that if you really worried about your diabetes and you are thinking that if you had an permanent home to stay, you would take better care of had an permanent home to stay, you would take better care of your diabetes and this is important to you. You are also worried your diabetes and this is important to you. You are also worried about getting attacked on the street again. You recovered from about getting attacked on the street again. You recovered from getting badly beaten up last year and you are worried that the getting badly beaten up last year and you are worried that the longer you stay on the street, that this could happen again. You longer you stay on the street, that this could happen again. You mentioned you are not quite ready to make a firm decision now, mentioned you are not quite ready to make a firm decision now, but I appreciate the chance to talk to you about housing services. but I appreciate the chance to talk to you about housing services. What did I miss? What did I miss?

End with:End with: “Would it be alright with you if we talked again in the “Would it be alright with you if we talked again in the future about housing services? When/where do you think we might future about housing services? When/where do you think we might do that?” do that?”

Needs for Future MI TrainingNeeds for Future MI Training

Training interestTraining interest

How should the training be delivered?How should the training be delivered?

Length and amount of time for training?Length and amount of time for training?